Management of Patients with Neurologic Dysfunction
1. Altered Level of Consciousness
- An altered level of consciousness (LOC) is apparent in the patient who is not oriented, does
not follow commands, or needs persistent stimuli to achieve a state of alertness. LOC is
gauged on a continuum with a normal state of alertness and full cognition (consciousness)
on one end and coma on the other end.
Causes:
- ALOC can be caused by a head injury, medicines, alcohol or drugs, dehydration, or some
diseases, such as diabetes.
Clinical Manifestations
- Changes in the pupillary response, eye opening response, verbal response, and motor
response.
Initial changes may be reflected by subtle behavioral changes such as:
- Restlessness or increased anxiety.
- The pupils, normally round and quickly reactive to light, become sluggish (response is
slower).
- as the patient becomes comatose, the pupils become fixed (no response to light).
- The patient in a coma does not open the eyes, respond verbally, or move the extremities in
response to a request to do so.
Assessment:
The neurologic examination should be as complete as the LOC allows.
- mental status
- cranial nerve function
- cerebellar function (balance and coordination)
- reflexes, and motor and sensory function.
- criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response
Diagnostic Findings:
- CT Scan
- MRI
- Positron emission tomography
- Electroencephalography
- Laboratory tests: blood glucose, electrolytes, serum ammonia, and blood urea nitrogen
levels, as well as serum osmolality, calcium level, and partial thromboplastin and
prothrombin times.
- Other studies: serum ketones and alcohol, drug levels, and ABG levels.
Complications:
- respiratory failure,
- Pneumonia
- Pressure ulcers
- Aspiration
- The patient with altered LOC is subject to all the complications associated with immobility,
such as pressure ulcers, venous stasis, musculoskeletal deterioration, and disturbed
gastrointestinal functioning.
Medical Management:
- Obtain and maintain a patent airway. (Orally or nasally intubated, or a tracheostomy may be
performed)
- Until the patient’s ability to breathe on his or her own is determined, a mechanical ventilator
is used to maintain adequate oxygenation.
- Monitor BP and heart rate
- An intravenous catheter is inserted to provide access for fluids and intravenous medications.
- Nutritional support, using either a feeding tube or a gastrostomy tube
Nursing Interventions:
- Provide an adequate airway and ensure ventilation.
- Protecting the patient by padded siderails are provided and raised at all times
- Maintaining fluid balance and managing nutritional needs
- Providing oral care
- Maintaining skin and joint integrity
- Preventing urinary retention
- Monitoring and managing potential complications
2. Increased Intracranial Pressure- Normal intracranial pressure is between 5-15 mmHg.
- is a rise in the pressure inside the skull that can result from or cause brain injury. is the
pressure in the skull that results from the volume of three essential components:
cerebrospinal fluid (CSF), intracranial blood volume and central nervous system tissue.
Causes
- Aneurysm rupture and subarachnoid hemorrhage
- Brain tumor
- Encephalitis
- Head injury
- Hydrocephalus (increased fluid around the brain)
- Hypertensive brain hemorrhage
- Intraventricular hemorrhage
- Meningitis
- Subdural hematoma
- Status epilepticus
- Stroke
Complications
- Death
- Permanent neurological problems
- Reversible neurological problems
- Seizures
- Stroke
Diagnostic Findings:
• CT scan
• MRI
• Positron emission tomography
• Transcranial Doppler (provide information about cerebral blood flow)
• electrophysiologic monitoring (monitors cerebral blood flow)
• LUMBAR PUNCTURE IS AVOIDED
Medical Mangement
- Sedation, drainage of CSF, and osmotherapy with either mannitol or hypertonic saline.
Nursing Interventions:
- Assess respiratory and neurological status
- Vital Sign’s Monitor and Documents (Plus,Blood Pressure)
- Check Laboratory Test such as CPP
- Administration oxygen as order
- Give medication therapy as order
- Maintain Nutritional and food status
- Maintain Diet plan give soft and healthy meal according to ditreation order
- Suction only as needed
- keep the patient in semi-Fowler’s positions
- promot healthy and comfortable environmental
- educate client’s about every kind of procedure
- assist with turning,coughing,and deep breathing
- Maintain the position and patency of the NG tube
- Enforce bed rest
- promote mouth care and skin care
- Maintain skin care change position every hourly to prevent bed sore
- Maintain seizure precautions
- Provide emotional support client’s and his family
3. Intracranial Surgery
- A craniotomy involves opening the skull surgically to gain access to intracranial structures.
This procedure is performed to remove a tumor, relieve elevated ICP, evacuate a blood clot,
and control hemorrhage.
Preoperative Management
- includes evaluating LOC and responsiveness to stimuli and identifying any neurologic
deficits, such as paralysis, visual dysfunction, alterations in personality or speech, and
bladder and bowel disorders.
- The patient’s and family’s understanding of and reactions to the anticipated surgical
procedure and its possible sequelae are assessed, as is the availability of support systems for
the patient and family.
- The patient may have a central and arterial line placed for fluid administration and
monitoring of pressures after surgery.
Postoperative Management:
- Reducing cerebral edema
- Relieving pain and prevent seizures
- Monitoring ICP
- Regulating temperature
- Preventing infection
Nursing Interventions:
- Maintaining cerebral tissue perfusion
- Regulating temperature
- Improving gas exchange
- Monitoring and managingpotential complications
- Monitoring for Increased ICP and Bleeding
- Managing Fluid and Electrolyte Disturbances
4. Seizure Disorders
- Episodes of abnormal motor, sensory, autonomic, or psychic activity (or a combination of
these) resulting from sudden excessive discharge from cerebral neurons.
Classifications:
Partial seizures (seizures beginning locally)
Simple partial (with elementary symptoms, generally without impairment of
consciousness)
- With motor symptoms
- With special sensory or somatosensory symptoms
- With autonomic symptoms
- Compound forms
Complex partial (with complex symptoms, generally with impairment of
consciousness)
- With impartment of consciousness only
- With cognitive symptoms
- With affective symptoms
- With psychosensory symptoms
- With psychomotor symptoms (automatisms)
- Compound forms
Generalized seizures (convulsive or nonconvulsive, bilaterally symmetric, without local
onset)
- Tonic-clonic seizures
- Tonic seizures
- Clonic seizures
- Absence seizures
- Atonic seizures
- Myoclonic seizures (bilaterally massive epileptic)
Nursing Management during a Seizure:
- Observe and record the sequence of symptoms.
- Before and during a seizure, the following are assessed and documented:
- The circumstances before the seizure (visual, auditory, or olfactory stimuli, tactile stimuli,
emotional or psychological disturbances, sleep, hyperventilation
- The occurrence of an aura (visual, auditory, or olfactory)
- The first thing the patient does in a seizure—where the movements or the stiffness starts,
conjugate gaze position, and the position of the head at the beginning of the seizure.
- The type of movements in the part of the body involved
- The areas of the body involved (turn back bedding to expose patient)
- The size of both pupils. Are the eyes open? Did the eyes or head turn to one side?
- The presence or absence of automatisms (involuntary motor activity, such as lip smacking or
repeated swallowing)
- Incontinence of urine or stool
- Duration of each phase of the seizure
- Unconsciousness, if present, and its duration
- Any obvious paralysis or weakness of arms or legs after- the seizure
- Inability to speak after the seizure
- Movements at the end of the seizure
- Whether or not the patient sleeps afterward
- Cognitive status (confused or not confused) after the seizure
- Preventing injury and supporting the patient.
Nursing Care Management after a Seizure:
- Document the events leading to and occurring during the seizure
- Prevent complications (eg, aspiration, injury)
- Patient is placed in the side-lying position to facilitate drainage of oral secretions and is
suctioned, if needed, to maintain a patent airway and prevent aspiration.
- Maintain seizure precautions
- Place bed in low position with side rails up and padded if necessary to prevent injury
The Epilepsies:
- A group of syndromes characterized by recurring seizures. Epileptic syndromes are classified
by specific patterns of clinical features, including age of onset, family history, and seizure
type.
Clinical Manifestations:
May range from a simple staring episode to prolonged convulsive movements with loss of
consciousness.
Diagnostic Findings:
Determining type of seizure, frequency and severity, and the factors that precipitate them
History taking, including events of pregnancy and childbirth, to seek evidence of preexisting
injury.
Patient is also questioned about illnesses or head injuries that may have affected the brain.
Physical and neurologic evaluations, diagnostic examinations include biochemical,
hematologic, and serologic studies.
MRI- used to detect lesions in the brain, focal abnormalities, cerebrovascular abnormalities,
and cerebral degenerative changes
Electroencephalogram (EEG) - aids in classifying the type of seizure
Single photon emission computed tomography (SPECT)- useful for identifying the
epileptogenic zone
Prevention:
- Careful monitoring of mothers , including blood studies to detect the level of antiseizure
medications taken throughout pregnancy
- High-risk mothers (teenagers, women with histories of difficult deliveries, drug use, patients
with diabetes or hypertension) should be identified and monitored closely during pregnancy
because damage to the fetus during pregnancy and delivery may increase the risk for
epilepsy.
- Highway safety programs and occupational safety precautions (head injury)
Medical Management:
- Management differs from patient to patient because some forms of epilepsy arise from
brain damage and others are due to altered brain chemistry.
Pharmacologic therapy:
NURSING ALERT!!!
- Nurses must take care when administering lamotrigine (Lamictal), an antiseizure medication.
- The drug packaging was recently changed to reduce medication errors as this medication has
been confused with terbinafine (Lamisil), labetalol hydrochloride (Trandate), lamivudine
(Epivir), maprotiline (Ludiomil), as well as the combination diphenoxylate and atropine
(Lomotil). Any patient given an incorrect medication may suffer adverse effects, and patients
with epilepsy are at risk for status epilepticus from having their medication regimen
interrupted.
Surgical Management:
- There may be a focal atrophic process secondary to trauma, inflammation, stroke, or anoxia.
If the seizures originate in a reasonably well-circumscribed area of the brain that can be
excised without producing significant neurologic deficits, the removal of the area generating
the seizures may produce long-term control and improvement
Status Epilepticus:
- (acute prolonged seizure activity) is a series of generalized seizures that occur without full
recovery of consciousness between attacks.
NURSE ALERT!!!
- continuous clinical or electrical seizures lasting at least 30 minutes, even without impairment
of consciousness. It is considered a medical emergency
Medical Management:
- Stop the seizures as quickly as possible, to ensure adequate cerebral oxygenation, and to
maintain the patient in a seizure-free state.
- Airway and adequate oxygenation are established.
- If the patient remains unconscious and unresponsive, a cuffed endotracheal tube is inserted.
- Intravenous diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cerebyx) is given
slowly in an attempt to halt seizures immediately.
Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state.
- An intravenous line is established, and blood samples are obtained to monitor serum
electrolytes, glucose, and phenytoin levels.
- EEG monitoring may be useful in determining the nature of the seizure activity.
- Vital signs and neurologic signs are monitored on a continuing basis
- An intravenous infusion of dextrose is given if the seizure is due to hypoglycemia.
- If initial treatment is unsuccessful, general anesthesia with a short-acting barbiturate may be
used.
Nursing Management:
- The nurse initiates ongoing assessment and monitoring of respiratory and cardiac function
- Administration of anti-seizure medications and sedatives to halt the seizures.
- Monitoring and documenting the seizure activity and the patient’s responsiveness.
- Patient is turned to a side-lying position if possible to assist in draining pharyngeal
secretions.
- Suction equipment must be available because of the risk for aspiration.
- The intravenous line is closely monitored because it may become dislodged during seizures.
- Patient should be protected from injury using seizure precautions and monitored closely
5. Headache
- One of the most common of all human physical complaints. Headache is actually a symptom
rather than a disease entity; it may indicate organic disease (neurologic or other disease), a
stress response, vasodilation (migraine), skeletal muscle tension (tension headache), or a
combination of factors.
- A primary headache is one for which no organic cause can be identified.
Types:
1. Tension - tend to be more chronic than severe and are probably the most common
type of headache.
- Characterized by sensation of tightness around head and neck
- Bilateral, non-throbbing (constant squeezing)
- Caused by sustained contraction of muscles, head and neck
- Precipitated by stress and anxiety, depression
- 90% adults, 20-40 years old
2. Migraine- Recurring vascular headache often initiated by triggering event and
accompanied by neurologic dysfunction
- Most common in females between 25-55 years old
- Attacks are w/in 4-72 hours
- Fronto-temporal, unilateral (pulsatile)
- Throbbing
- Family history often positive
- Associated with nausea, photophobia, blurred vision, noise
3. Cluster-
- are a severe form of vascular headache. They are seen five times more frequently in men than women
- Typically awakens client with unilateral pain around eye accompanied by rhinorrhea –
- 60% bilateral
- 40% orbits temporal/unilateral
- Common: adolescent/ adult males (90%)
- Factors: alcohol; smoking
4. Cranial arteritis- is a cause of headache in the older population, reaching its greatest
incidence in those older than 70 years of age.
Clinical Manifestations:
1. MIGRAINE
Prodrome:
- experienced by 60% of patients with symptoms that occur hours to days before a migraine
headache.
Symptoms:
- depression
- Irritability
- feeling cold,
- food cravings
- anorexia
- change in activity level
- increased urination,
- diarrhea, or constipation.
Aura Phase:
- The aura usually lasts less than an hour and may provide enough time for the patient to take
the prescribed medication to avert a full-blown attack.
- This period is characterized by focal neurologic symptoms. Visual disturbances (ie, light
flashes and bright spots) are common and may be hemianopic (affecting only half of the
visual field).
Other symptoms:
- numbness
- and tingling of the lips, face, or hands;
- mild confusion; slight weakness of an extremity; drowsiness; and dizziness.
Headache Phase.
- As vasodilation and a decline in serotonin levels occur, a throbbing headache (unilateral in
60% of patients) intensifies over several hours.
- Its duration varies, ranging from 4 to 72 hours
Recovery Phase.
- (Termination and postdrome), the pain gradually subsides.
- Muscle contraction in the neck and scalp is common, with associated muscle ache and
localized tenderness, exhaustion, and mood changes
Managements:
- Sumatriptan has been found to be effective in relieving moderate to severe migraines in a
large number of adult patients.
- The medical management of an acute attack of cluster headaches may include 100% oxygen
by face mask for 15 minutes, ergotamine tartrate, sumatriptan, steroids, or a percutaneous
sphenopalatine ganglion blockade
- The medical management of cranial arteritis consists of early administration of a
corticosteroid to prevent the possibility of loss of vision due to vascular occlusion or rupture
of the involved artery
1. Tension- analgesics, muscle relaxant
2. Migraine- analgesics, vasoconstrictor, A-adrenergic blocker, corticosteroid, serotonin
receptor antagonist, anti-depressant
3. Cluster- vasoconstrictor, o2 therapy, A-adrenergic blocker
Nursing Management:
- Relieving pain (Regular sleep, meals, exercise, avoidance of peaks and troughs of relaxation,
and avoidance of dietary triggers)
- Teaching patients’ self-care use of Nonpharmacologic therapies are important and include
patient education about the type of headache, its mechanism (if known), and appropriate
changes in lifestyle to avoid triggers
- Continuing care
